Catholic moral theologians debate the moral value of the organ donation because of the principle of totality and integrity, which states that the body should be kept whole unless the removal of a body part is necessary for the body’s overall health. This principle protects the dignity of the body as part of the human person. This philosophy of the human body stands at odds with other philosophies within our culture that see the body as a mere vessel for the spirit, or that see the human person as no more than a physical animal. There is also question about whether or not a human person is truly dead with the organs are harvested. Complete bodily death leads to the immediate deterioration of organs. Some organ donation advocates want to create a new category of “death” that allows for the harvesting of organs before the body is completely dead as long as it is reasonably certain that the patient will not regain consciousness and that the brain activity has fallen below a level defined as the standard for life. This places the value of the organ donor’s life below that of the organ recipient because the organ donor’s life is considered useless. The definition of brain death is debated among moral theologians.

Besides questions about the morality of organ harvesting in general, there is also the question about free will. If organ donation is deemed morally acceptable, it is because it is a free gift of one’s body for the good of another, and therefore an act of love. However, if organ donation is forced by law, this free act of love is diminished or even destroyed. Furthermore, our culture runs the risk of becoming utilitarian, judging one life against the other based on some standards of quality that are purely materialistic and that do not recognize the dignity and value of each human person.

Any way you look at it, the New York law is a problem. Yes, it could save lives by making more organs available for transplant, but only at the expense of devaluing other lives. It could put doctors in the position of making value judgments that determine that one person’s life has less value than another person’s. It could be one more step in the culture of death to devalue human personhood and to make life, our bodies, and our very lives into nothing more than a commodity for the highest bidder.

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While many medical care professionals are caring, compassionate individuals who diligently care for all patients no matter what their state, utilitarian attitudes continue to creep into the medical culture. Evidence can be found in articles such as, “The undead” from the December 9, 2007 issue of The Sunday Times.

The overarching attitude is that to live in a state of unresponsiveness is a terrible cause of suffering. The author of this article borders on adopting this attitude,

More certain is the grim reality of hospital wards and long-term care homes where the persistently vegetative and the minimally conscious languish, sometimes for decades.

To write this article I have had the sobering experience of witnessing the plight of patients with severely impaired consciousness – the intubations, the double incontinence, the stricken semicircle of wheelchairs parked before the unwatched day-room TV. And I have met the anguished families of those who are denied final grieving and closure for a loved one condemned to what appears a living death. All too often I have spoken to a wife or husband, or mother or father, who will travel anything up to two hours each way by taxi, every day, to spend time with an unresponsive child or spouse.

There is no doubt that an unresponsive state causes suffering for the patient and for the family. However, as I explored most recently in “The Language of the Culture of Death,”, suffering can have great value. The quote above shows how much a patient’s suffering can draw her family toward love.

The article offers anecdotal evidence that unresponsive patients are often neglected. They are given poor care and no therapy. It is almost as if the medical establishment says, “Oh well – he’s not really alive anyway. Let’s not waste our time.”

Up to 12,000 people under 40 in this country suffer traumatic brain injury every year, and there are serious deficiencies in their rehabilitation, according to Professor John Pickard, head of neurosurgery at Addenbrooke’s hospital, Cambridge: “The tendency for patients to be left to languish on general medical, surgical and orthopaedic wards continues to their detriment.” The shocking term being used by campaigning neurologists and neurosurgeons is that unknown numbers of patients are being just “warehoused”.

The depersonalization of these patients is much to their detriment, especially since mounting evidence shows that the assumption that a patient is in a “persistent vegetative state” is often wrong.

The biggest, most tragic clinical myth about brain injury today is that PVS can be reliably diagnosed by bedside observation alone. It has in fact been known for at least a decade, ever since a key survey of brain-injured patients, that misdiagnosis of the condition runs at more than 40%, a statistic originally calculated by Professor Keith Andrews, former head of the Putney hospital, and confirmed by recent surveys in Europe and North America. This means that valuable rehabilitation strategies are routinely neglected, and misdiagnosed patients end up on unsuitable wards or in care homes where their needs are neither understood nor met.

One rehabilitation psychologist pointed out that consciousness needs to be exercised just like a muscle. If a patient is neglected and denied treatment (as was Terri Schiavo, for example), there will be no progress toward awareness. If consciousness is exercised (balanced with periods of rest), consciousness can strengthen. Patients who are neglected due the assumption that their lives are useless are denied this chance.

However, even patients who have no chance for recovery deserve better than they often get. Loss of awareness does not mean loss of human dignity or personhood. Once again we see the weakness of the naturalistic “personal autonomy” ethic that is trying to replace the ethic of human dignity. As the article points out (after a quick anecdote),

Even minimally aware patients can retain emotions, personality, a capacity to suffer – and, as the young biker showed, attitude.

While the main point of this article was to point out that patients are often misdiagnosed with PVS, and that doctors are devising scans that can offer a more accurate diagnosis of the extent of brain damage, the article also brings up the question of the treatment of any unresponsive patient.

The Cambridge project is not, however, without potential ethical and social problems. Scanning for minimal consciousness in those who appear vegetative can in some cases yield ambiguous results. Evident brain reactions can sometimes be fickle: now here, now gone. Some experts worry the technology could have drastic consequences for relatives where there is scant prospect of a patient’s return to interaction. At the Putney hospital, which houses more than 220 brain-injured and neurological patients, I was told by a research psychologist about a patient in a PVS of about three years’ duration, known as Mrs K, whose family might well be devastated if a scan were to reveal indications of awareness.

The main reason for removing nutrition and hydration from unresponsive patients is to release the family from the obligations of love – to “allow them to get on with the grieving process.” However, these people are not in “the dying process.” Their bodies are not shutting down. They are not brain dead (which leads to the failure of bodily functions). They are simply unresponsive. When nutrition and hydration are removed, these patients die of thirst just like any fully responsive person denied of food and water would.

More heinously, the article points out that there is increasing pressure to declare PVS patients dead so that their organs can be harvested. The attitude that feeds this pressure is that their lives are useless, so their death may as well benefit someone who has a chance to live a “real” (productive) life. This is the same attitude that attempts to justify cannibalizing unborn babies to benefit the health of “really living” human beings.

Brain damage that leaves a patient unresponsive causes great suffering from everyone touched by it. We need to decide if that suffering will draw us to love or if we will give in to the philosophy that would devalue our loved ones in their time of greatest need.

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While it is true that the term “in principle” does connote possible exceptions, such a phrase does not give moral theologians and ethicists freedom to allow for any exceptions they see fit. There is a hierarchy of moral truth:

• Moral laws: these are inviolable – derived from the way God made us as human beings (natural law) and by His Divine Revelation that instructs in our relationship with Him.
• Moral principles: these are derived from moral law in order to give us direction for following it. Since they are human formulations, they may be revised. However, because they are derived from the inviolable moral law, they are very solid and are changed carefully and rarely. They must remain true to the moral law.
• Moral formulations (theories & models): these are attempts to apply general moral principles to very specific circumstances. They may be argued and changed, but always with the goal of staying as true to moral principles as possible. The Ethical and Religious Norms – ERDs – fall here.
• Prudential decisions: these are individual choices in an attempt to attain the greatest good to which the moral law guides us. Here is where we as individual get it right or get it wrong. Prudential decisions should be oriented toward fulfilling the moral law, using the principles and theories/models/formulations to get there. These choices are choices of conscience, which should be formed by the moral law, principles and formulations.

Dr. Hardt seems to lose sight of this hierarchy when he states:

When interpreting and applying the documents of the Holy See, there are a number of traditional norms, some dating back to the early days of church legislation. Most of these norms were collected in the Rules of Law (Regulae Iuris) in the Libro Sexto of Pope Boniface VIII in 1300. Many of the rules are repeated in one way or another in the present Code of Canon Law. Two canons of the present code are relevant for our study:

• Canon 18: “Laws which establish a penalty or restrict free exercise of rights . . . are subject to strict interpretation.”
• Canon 52: “A singular decree has force only in respect to the matters which it decides and for the persons for whom it was given.”

Hence, the application of the CDF response, because it limits the free exercise of rights, will only apply to a restricted number of cases, specifically to patients with a firm diagnosis of PVS. Some commentators have sought to extend the statement to people with other pathologies, such as advanced Alzheimer’s disease or acute dementia. But the response concerns only patients who are diagnosed as being in a persistent vegetative state, not to all patients who are unable to assimilate food and water without artificial assistance. If the CDF wanted to extend this teaching, it could use another form of communication, for example, an Apostolic Instruction. Moreover, because the questions were presented by the U.S. bishops, the response applies only to them and the ecclesiastical communion for which they are responsible, not, for example, to the church in Canada or Australia.

The laws and decrees to which these canons refer are laws and decrees of canon law, or of specific legislation. They do not refer to statements that reiterate or clarify moral law or moral principles. Moral decisions often “limit freedom” when freedom is incorrectly defined as the ability to choose whatever you want to choose. However, when you define freedom truly, as the power to choose what is good, such statements actually lead us to true freedom. Statements such as the one to the American bishops from the CDF are part of the ongoing teaching of the Church about the universal moral law.

Dr. Hardt talks about certain presuppositions made by the CDF that would lead to certain exceptions to the general principle:

Presuppositions of the CDF Response
When applying the CDF response, some of its presuppositions can be called into question, potentially disposing of more exceptions on the part of care givers than are indicated in the CDF response. Following is a consideration of some of these presuppositions as they relate to the tradition of the church on this matter.

The CDF proposes that ANH “does not involve excessive expense.”

The majority of the authors of the CDF response come from countries in which universal health coverage is a given. The situation here in the U.S. is obviously different and often poses significant financial hardships for the caregivers of patients in PVS, third-party payers or the civic community. The possibility that the immediate caregivers may not be financially burdened does not mean that the cost of caring for patients in PVS is negligible. The vast majority of patients who receive ANH in the U.S. receive their care in hospitals or long-term care facilities, both of which may very well impose “excessive expense” on one or all of the entities mentioned above.

It is certainly true that financial burden on the relatives of a comatose or incapacitated patient is one consideration when determining whether a treatment is ordinary or extraordinary. However, such financial burden needs to be severe to qualify the treatment as an extraordinary means. Furthermore, such families should not face the burden of medical care alone. They should have the help of the community. Finally, the great expense in America is not really associated with feeding and hydration. It is rather due to the exorbitant way in which patients are charged – including full doctor charges for brief visits. The added expenses for sustaining treatment are truly a social justice issue. The changes need to be made in the medical establishment, not in the decision whether or not to offer sustaining treatment.

The CDF proposes that the purpose of ANH “is not, nor is it meant to be, a treatment that cures the patient, but is rather ordinary care aimed at the preservation of life.”

The CDF’s suggestion that ANH is not meant to be a treatment that cures a patient is not congruent with human experience in the hospital and long-term care setting. When families, in consultation with a clinical care team, initiate ANH for a loved one, it is usually done so with the intent and hope for substantive recovery. Moreover, persons are increasingly designating in advanced directives or by oral communication their clear desire to not receive ANH if there is no hope of cognitive recovery. These wishes reflect an attitude recognized in moral theology as psychic aversion (horror mentis). This attitude arises because people feel that such care does not truly benefit a patient in a permanently comatose condition and that it will often place a burden upon the loved ones giving care. As mentioned above, it is not unreasonable to interpret the CDF response as recognizing the possibility of this attitude.

Dr. Hardt splits hairs here to point out a difference that doesn’t really exist. The CDF’s statement that food and water are not given as a treatment indicates that the food and water themselves have no medicinal value. Dr. Hardt is referring to the desire to extend someone’s life in hope that time will heal the person. This does not put food and water into the realm of curative treatment. Why does this difference matter? A patient is able to deny any curative treatment that does not hold much hope of being effective. However, food and water may not be denied because they are basic to human life. Even if there is not much hope of recovery, food and water must be administered. If an extraordinary form of curative treatment is denied, the result may be death due to the illness. However, if food and water are denied the death is due to starvation or dehydration. There is a big difference here.

Hundt’s claim that moral tradition has held that patients may deny life support in order to avoid the form of suffering called “psychic aversion” on behalf of loved ones is also questionable. Life support that replaces or aids a failing bodily function may be considered extraordinary care, since the organ has failed anyway. However, giving someone food and water that the body is able to use and that the body needs for survival is not extraordinary and may not be refused by the patient. It is exactly the attitude that a person’s suffering poses and undue burden on loved ones that the Church’s moral tradition has sought to avoid. It is not permissible for me to kill off my grandmother because I’m sick of waiting around for her to die. It is equally not permissible for my grandmother to refuse ordinary means of sustaining her life so that she does not burden me. A person’s suffering and life have value – they are not burdens.

The CDF proposes that if ANH is removed, the cause of death “will be neither an illness nor the ‘vegetative state’ itself, but solely starvation and dehydration.”

Here, the CDF offers an interpretation of what kind of act constitutes euthanasia. This interpretation is at odds with the traditional teaching of moral theology. When life support is removed because it does not offer hope of benefit or imposes an excessive burden, the cause of death is the pathology which is no longer abated or circumvented. This is at the heart of the distinction between the licit removal of life support and passive euthanasia. This distinction has been explained by several Catholic moral theologians of the past, and its misconception, as expressed in this document, would call into question the removal of any form of life support under any conditions.

Here again Hundt fails to differentiate between “life support” that takes over for a failing (or failed) bodily system and a mechanized method of ordinary sustenance. If a disease or bodily trauma has caused my heart to stop, I may be on life support that keeps my heart beating in hope that my body may heal in time. Taking me off such life support because that hope is too small to balance the burden on me and my loved ones would be morally licit because the disease or trauma has stopped my heart and turning off life support would do nothing more than allow death to take its course. Taking away food and water is not the same. The absence of food and water would kill me whether or not I had the disease or trauma.

While this is an important distinction, I’m not sure Hundt is correct in claiming that it is at the heart of the differentiation between licit and illicit (he is oversimplifying). If there is hope of recovery or if the burden of a heart machine is not excessive, it would not be illicit to remove it either.

The CDF proposes that if care is “prolonged over time,” it may constitute an excessive burden.

The CDF response does admit that caring for a PVS patient over time may be a notable burden. This is similar to the recognition of family burden offered by Pope John Paul II in his original allocution on care of PVS patients. The bishops of the United States issued some “talking points”—in the form of a Q&A—when they released the response they had received from the CDF, and they suggest that the main burden for the care givers will be financial. They also suggest that Catholic health care facilities and the Catholic community should offer assistance and provide “concrete examples of the Church’s commitment to human life.”6 Once again, given the psychic aversion to continuing care for comatose people who will never recover consciousness, it is questionable whether the Catholic community will respond to this challenge.

Once again Hundt brings up psychic aversion. There is no doubt that the emotional and moral suffering of a family with a seriously ill loved one is very real and intense. However, this is not the kind of suffering that may be considered as part of the burden of treatment. This is suffering caused by the illness, not suffering caused by the treatment. What people suffering from psychic aversion need is support and counseling, not the death of their suffering loved one. Only when they see the beauty of the person’s life and the value of their suffering will psychic aversion be properly dealt with. To allow ordinary means of sustenance and treatment to be denied due to the burden of psychic aversion would lead only to guilt that they wanted their loved one to die.

Medical ethics in our area are often carried on by people like Dr. Hundt. These “ethicists” fail to understand the proper role of the magisterium. They also often take very myopic views of moral tradition and fail to apply principles such as “growth through suffering.” The fact that Catholic hospitals are rationalizing their way to the Culture of Death should scare us all.

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